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09010129 OF CUPERTINO ILD DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 1 n1 29 10 19 A T W T PERMIT ISSUE DATE OWNER'S NAME. q�YU. CONTROL NO. (8 0 0) 454-8955. BUILDING PERMIT INFO ARCH I7-CTIENGiNEER: BLDG ELECT PLUMB MECH 249 C LICENSED CONTRACTOR'S DECLARATION Job Description V I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is RMV/RP LC GAS WATER HEATER e y in full force and effect n Z License Class Liuador y Date Uj ARCHITECTS DECLARATION I understand my plans shall be used as public records m r w in Licensed Professional 0< OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the eN O following reason.(section 7031.5,Business and Professions Code:Any city or county S. which requires a permit to construct alter,improve,demolish,or repair any structure Valuation prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q' $449 YtZ G (commencing with Section 7000)of Division 3 of Uro Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fire hundred dollars(s5W). 39507034 . 00 ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Businesa Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. cense Law does not apply to an owner of property who builds or improves thereon,and, who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. B&P C for this reason ❑1 am exempt under Sec. Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insure forworkees Compen- -tion,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance.as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, My Workers Compensation insurance carrier and Policy number am: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(S 100) or lass.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code you must ,J,Z forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY E.r hr I hereby affirm that there is a construction lending agency for the performance of p, the work for which this permit is issued(Sec.3097,Civ.C.) W Lenders Name ] Z Lenders Address V C) 1 certify that I have read this application and state that the above information is correct 1 agree to comply with all city and county ordinances and stale laws relating to c Vbuilding construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against In liabilities,judgments,costs and expenses which may in any way accrue against said City V Zin consequence of the granting of this permit. Date r-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roofs Signature of Applicant/Contractor Dam Type of Roof HAZARDOUS MATERIALS DISCLOSURE yP Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. []Yes ONO If a roof is installed without first obtaining an inspection,I agree to remove will the applicant or future building occupant use equipment or devices which it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. .strict? [3 Yes ❑No 1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant that it is my responsibility to notify the occupant of the Date requirements which mast be mel prior to issuance of a Certificate of Occupancy. Signature of Applicant All roof coverings to be Class''{``or better Owner or authorized agent Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 39507034 . 00 DATE ISSUED. . . . . . . : 01/30/2009 RECEIPT # . . . . . . . . . BS000007074 REFERENCE ID # 09010129 SITE ADDRESS 10190 S TANTAU AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : TANG, CHAOYANG ADDRESS . 10190 S TANTAU BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JEFF JORDAN CONTRACTOR . . . . . . . : JEFF JORDAN LIC # 29100 COMPANY . . . . . . . . . . : FAST WATER HEATER ADDRESS : 12601 132 AVE NE CITY/STATE/ZIP . . . : KIRKLAND, WA 98034 TELEPHONE . . . . . . . . : (800) 454-8955 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- - 1BCBSC VALUATION 449 .00 1 . 00 0 . 00 1 . 00 0 • 1BSEISMICR VALUATION 449 .00 0 . 50 0 .00 0 .50 0 .00 1PPERMITFE FLAT RATE 1 .00 40 .79 0 . 00 40 .79 0 .00 1PRWHEATR UNITS 1 .00 24 .48 0 . 00 24 .48 0 .00 1TRAVDOC FLAT RATE 1 .00 40 .79 0 . 00 40 . 79 ------0_00 ---------- ---------- ---------- TOTAL PERMIT 107 . 56 0 . 00 107 . 56 0 .00 METHOD OF PAYMENT AMOUNT --REFERENCE NUMBER ----------------- ------------- CREDIT CARD 107 . 56 VISA --------------- TOTAL RECEIPT 107 . 56 VOICE ID DESCRIPTION VOICE ID DESCRIPTION - -------- ------------------------ ------- ------------------------ 518 WATER HEATER p431627 Permit No: 1 (office use only) City of Cupertino Building Permit Application E-Mail: Buildina-Permits cupertino.ora (Address is case sensitive). Jobsite Address:10190 S TANTAU BLVD Date: 1129109 Assessor's Parcel Number: — .���4 , Do Owners Name: TANG, CHAOYANG Phone No: (408)253-7553 Project Valuation: 449.00 Building Permit info: Bid Elect Plumb x Mech Job Description Remove/Replace Gas Water Heater Contractor information Company Name: FAST WATER HEATER COMPANY Phone No: Contact Name: Julie Caskey Fax No: 425-636-7084 Address: 12601 132ND AVE NE E-mail: carolr@fastwaterheater.com City, State&zip code: KIRKLAND,WA 98034 State Contractor's Lic. No: 877489 Expiration Date: 5/31110 Worker's Comp No: A09304455 Expiration Date: 12/1109 Carrier Truck Insurance Exchange City of Cupertino Business License No: 29100 Credit Card Information Credit Card No: Expiration Date: 11/10 Name on Card: Jeff Jordan Visa ] MasterCard ❑ American Express ❑ The Building permit application and a completed &signed contractorlsubcontractor form need to be submitted with each permit. , Commmsity Development 10300 Torre AveUW Cupertino CA 95014 Tele&cme(408)777-3228 I&a Fax(408)777-3333 cuPE INO Buildin De axtment JOS ADDRESS: 10190 S TANTAU BLVD r WIT#©q ()1 0' OWNER'S NAME: TANG, CH YANG PHONE# (408)263-7553 GENERAL CONTRACTOR:FAST WATER HEATER COM PA FAX# 425-636-7085 I am not using any subcontractms:.__ 1 Date Signature Please check a licable subcontractors and complete the followinginformation: SU13CONTRAc rOR BUSINESS NAME BUSINESS LICENSE# Cabinets&Millwork Cement Fixdshing IIectracal Excavation Pencin Flooring:Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date